The California Department of Public Health announced last week that it had fined nine hospitals a total of $775,000 for 10 incidents, and like the list released last August, it included safety violations that resulted in serious injury and death.
Fines ranging from $50,000 to $100,000 were meted out to medical centers in seven counties for incidents like the removal of the wrong kidney during an operation or a "leftover" surgical device left behind in a patient..
Some of the cases date back to September 2011, but have only recently been closed.
AlvaradoHospitalMedicalCenter in San Diego–The patient had been admitted after a complaining of frequent falls and suffered a fall at a skilled nursing facility the day before admission to the hospital. A registered nurse turned off the bed alarm for the high-fall-risk patient, who then fell out of bed, hit her head and died the next day from bleeding in her brain. It was the hospital’s first administrative penalty. $50,000
AntelopeValleyHospital in Lancaster (Los AngelesCounty)–A patient underwent successful surgery for a bowel obstruction, but returned to the emergency room twice after release for abdominal pain. The patient was given pain meds each time and sent home. A third visit to emergency prompted a CT scan that detected a leftover surgical “fish” device. It was removed during a second surgery. It was the hospital’s first administrative penalty. $50,000
CommunityRegionalMedicalCenter in Fresno–A patient was given an epidural catheter to deliver pain medication to the spine. The catheter was prematurely removed while blood thinners were still being administered, resulting in paraplegia from the waist down. It was the hospital’s second administrative penalty. $75,000
CommunityRegionalMedicalCenter in Fresno–A heart surgeon left the operating room and the hospital, leaving others to close up the chest after surgery. The patient went into cardiac arrest and was eventually placed on life support. It was the hospital’s third administrative penalty. $100,000
LAC/Harbor-UCLA Medical Center, Torrance–A misunderstanding about a patient’s surgical history incorrectly indicated a right-knee replacement would not require a blood transfusion. Ensuing complications caused a large loss of blood and forced amputation of the leg above the knee. The patient was eventually discharged, complained of problems, was admitted to another hospital and died there. It was the hospital’s fifth administrative penalty. $50,000
MercyMedicalCenter in Merced–A 2-and-a-half month old child suffered a third-degree burn to its palm when a nurse used a “vaginal light” to examine the infant’s hand after repeated failures to insert an intravenous tube for treatment. The light is not designed for that purpose and the burn later required skin grafts. It was the hospital’s first administrative penalty. $50,000
MissionHospitalRegionalMedicalCenter in Mission Viejo–A registered nurse who wasn’t cleared to remove central line catheters, including those from a jugular vein, did it anyways, and did it improperly. The patient went “code blue” and collapsed, but was resuscitated and sent home by the doctor, who noted, the man “had some problems with confusion, but at the time of discharge, his mental state was markedly improved.” It was the hospital’s seventh administrative penalty. $100,000
Santa ClaraValleyMedicalCenter in San Jose–A pharmacist inadvertently prepared chemotherapy medication for two patients that had 16.6 times the prescribed dose of methotrexate. The preparation process involved internal checks using three pharmacists. Both patients ended up in intensive care. It was the hospital’s fourth administrative penalty. $100,000
SharpMemorialHospital in San Diego–A patient admitted with abdominal pain was diagnosed with a suspected cancerous mass in the right kidney. Radiology images from the first hospital were not viewed by the second hospital (presumably Sharp Memorial). A subsequent surgery at a second hospital resulted in the left kidney being removed. The patient will need on-going dialysis to survive. It was the hospital’s fourth administrative penalty. $100,000
St. Jude Medical Center in Fullerton (Orange County)–A 93-year-old patient, noted for “impulsive behavior did not use a call light, was using a walker for ambulation, had received a sedative-hypnotic, and had urgency when needing to use the rest room,” was to be watched carefully. Fall-alert procedures were in place, but the patient still managed to hit the floor, crack his head and subsequently die. It was the hospital’s sixth administrative penalty. $100,000